Auto Claim

Auto Claim

Contact Information

Last Name*

First Name*

Email Address*

Phone Number*

Alternate Phone

Policy Number:

Name of Insurance Company on Policy:

Vehicle Involved

Make

Year

Loss General

Date of Loss (DD/MM/YYYY)

Cause of Damage:

Estimated Damage

Drivers Information

The following section is applicable to Accident only

Driver First Name

Driver Last Name

Relationship to Applicant:

Time of Accident

Number of Cars Involved:

Police Notified: Yes No

Estimated Percentage at Fault: 50% or Less 51% or more

Photo of Damage

Location of the Accident

Last 3 years (minor violations) / Last 5 years (major violations)

Street / Highway

City / Town

State

Short Description (250 chars left)

Other Party Information (if available)

Last 3 years (minor violations) / Last 5 years (major violations)

Photo of Other Driver License

Photo of Other Driver Proof of Insurance

Photo of Other Vehicle License Plate

Photo of Other Vehicle Damage

Other Driver Name

Address

Home Phone

Work Phone

Driver's License

License Plate Number

License Plate State

Insurance Company

Policy Number

Vehicle Year/Make/Model

Short Description (250 chars left)

The following section is applicable to Theft only

Time Loss Discovered

Date Police Notified (DD/MM/YYYY)

Vehicle Recovered Yes No

Date Vehicle Recovered (DD/MM/YYYY)

Short Description (250 chars left)

Online Claim Notice I understand that any person who files a claim with the intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

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Questions or Comments (1000 chars left)

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